Provider First Line Business Practice Location Address:
610 8TH ST APT 6
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83501-2672
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-595-5179
Provider Business Practice Location Address Fax Number:
509-595-5179
Provider Enumeration Date:
06/12/2025